| First Name: _____________________ | Last Name: ______________________ |
| Affliation: ______________________ | Email: __________________________ |
| Street Address: | Telephone: _______________________ |
| ___________________________ | FAX: ___________________________ |
| ___________________________ | Name on Badge: __________________ |
| City: ___________________________ | State/Provence: ____________________ |
| Zip/Postal Code: ____________ | Country: __________ |
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| Dietary Restrictions: Vegetarian | Other (specify): ________________ |
| Credit Card (please check one): |
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| Credit card number: | ____________________________________ | ||
| Expiration Date: | ____________________________________ | ||
| Name as it appears on the credit card: | ____________________________________ | ||
| Total Charges Authorized: | $190.00 | ($220.00 if received after Sept 25) | |
| Signature: | ____________________________________ | ||
| Do you need a hard copy receipt? | [ ] YES [ ] NO |
Please note that by signing above, your credit card will be charged $190.00 (or $220.00 if received after September 25th).
For further information please contact the workshop chairs.